Patient Evaluation

We would like to know how you feel about the services we provide so we can make sure we are meeting your needs. Your responses on the patient evaluation form are directly responsible for improving our services. Feel free to enter as much information as you want. All responses will be kept confidential and anonymous.

Thank you for your time!

Patient Evaluation

Today's Date*

Which Clinic did you visit?*

Summit Medical Associates in Atlanta

Summit Women's Center in Detroit

What type of service did you receive from us?*

How do you think we are doing?*

Great

Good

Need Improvement

Ability to get in for an appointment at this facility?*

Great

Good

Need Improvement

How was the patient representative who made your appointment?*

Great

Good

Need Improvement

The responsiveness and politeness shown by our front desk staff?*

Great

Good

Need Improvement

The amount of time our treatment coordinator spent with you?*

Great

Good

Need Improvement

The professionalism of our treatment coordinator?*

Great

Good

Need Improvement

Did the clinician answer your questions?*

Great

Good

Need Improvement

Was the exam room and/or surgical suites neat and clean?*

Great

Good

Need Improvement

Did the nurse listen to your requests?*

Great

Good

Need Improvement

The overall care provided to you?*

Great

Good

Need Improvement

Keeping your personal information private?*

Great

Good

Need Improvement

How important are the following to you?

Courtesy*

Very Important

Indifferent

Not Important

Price*

Very Important

Indifferent

Not Important

Would you recommend Summit Medical Centers to a friend and/or relative?*

Yes

No

Not Sure

What did you like the BEST about our center?

What did you like the LEAST about our center?

Would you like for a manager to contact you to discuss any concerns or questions?*

Yes

No

First & Last Name (must be provided to validate the legitamcy of this feedback form - Strictly Confidential)*

FirstLast

Phone Number (if you wish to be contacted)

To ensure that this is a true patient's information please enter the numbers and letters you see on the right.

Patient Comments

"Best doctor in Detroit. This was a tough decision, but your staff made me feel safe and confident with my decision. Thanks so much!"

"I am very pleased with your staff. Everyone made it as comfortable as possible. Thanks for everything!"